We are looking for a Medical Claims Analyst to support a commercial health plan review and audit initiative. The analyst will help evaluate medical claims for accuracy, compliance, and audit readiness while partnering with internal stakeholders to address issues and support timely resolution.
Responsibilities:
Examine commercial medical claims to confirm correct processing, payment accuracy, and adherence to applicable audit standards.
Investigate claim records specifically surrounding the No Surprises Act (NSA) and supporting documentation to uncover variances, exceptions, and items that require follow-up or correction.
Validate claim details during audit-related reviews and maintain organized documentation to support findings and recommendations.
Work closely with operational and compliance teams to resolve claim discrepancies and promote alignment with regulatory obligations.
Assess denied, rejected, or adjusted claims to identify patterns, root causes, and opportunities for process improvement.
Review claims across multiple jurisdictions and plan structures to ensure consistent interpretation of commercial health plan requirements.
Use healthcare claims data and related systems to track issues, document outcomes, and support reporting on audit activities.
